Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Original Research Kut and Geçkil Vaccination Status in Children under 8 Years and Attitudes of Their Parents Altuğ Kut, Ali Ümit Geçkil Başkent University, Faculty of Medicine, Department of Family Medicine, Ankara ABSTRACT Vaccination Status in Children under 8 Years and Attitudes of Their Parents Background: Vaccination plays a key role in preventive medicine worldwide. Turkey has adapted an advanced national extended vaccination program (NEVP) in recent years. Accordingly, vaccination coverage rose dramatically in recent years. Attitudes of Parents are playing an inevitable role in the challenges toward vaccination issues. Aim: This study aims to determine the demographic traits, vaccination status, and attitudes of their parents regarding vaccination approaches. Design of Study: This study is designed as a cross-sectional observational survey Setting: The study was carried out at the pediatrics outpatient clinic of the Baskent University Ankara Hospital Methods: Parents with children aged 0-8 were asked between March – June 2013 to join the study voluntarily. 150 parents answered to a 12-item questionnaire. Data were analyzed using SPSS software. For descriptive statistics mean±SD, minimum-maximum levels and percentages were used; continuous variables were analyzed using t- test and categorical variables using Chi-square tests. P values < 0.05 were accepted as statistically significant. Results: In total 219 children of 150 families were enrolled. Mean age of the children was 2.73 years and all of them were fully vaccinated. Most were living in the city center (76.7%). Of the parents, 10.7% were against paid vaccines, while 2% couldn’t afford them. 42% of families were positive about the HPV vaccine. Most of the families preferred their family physicians both in urban and rural areas for vaccination (61.7%, 68.6% respectively). Conclusion: The initiation of Family medicine in Turkey and the application of the NEVP have positively affected parents’ approaches towards vaccination. Key Words: Childhood vaccination, Vaccination rates, Vaccination coverage, Parental attitudes Kut A, Geçkil Ü. Vaccination Status in Children under 8 Years and Attitudes of Their Parents. Turkish Journal of Family Medicine and Primary Care2014;8(3):68-74. DOI: 10.5455/tjfmpc.154621 . Introduction Vaccination plays a key role in preventive medicine worldwide. National vaccination policies of countries decreased both morbidity and mortality of childhood contagious diseases significantly in the past decades. Efforts towards improving national vaccination programs are still ongoing in several countries that are led by national committees, and international organizations like 1 the CDC, and WHO. Similar efforts are also valid in Turkey, and a national vaccination program (Figure-1) is continuously updated to meet recent 2-4 national health care strategies. Accordingly many campaigns are performed to eradicate or lower prevalence of certain childhood contagious 2 diseases. Corresponding author: Altuğ KUT, Başkent University, Faculty of Medicine, Department of Family Medicine, Ankara, Turkey. E-mail: [email protected] Received Date: April 15, 2014 Accepted Date: May 21, 2014 Vaccination as a phenomenon is a complicated procedure, which has lots of social, 2 cultural, financial, and political aspects. It is presumed that success rates of pediatric vaccination especially depend on parental age, educational status, attitudes, and knowledge towards the whole vaccination 2,3 procedure. According to Turkey Demographic, and Health Survey (TDHS-2008) there are many variables causing disparities regarding the status of 3 being fully vaccinated. Geographical region, and settlement area differences as well as the educational status of motherscan be counted as 3 some of these variables. According to TDHS-2008 study the rates of fully immunized children in eastern Anatolia were found to be less compared to other Turkish regions (64%); followed by Northern, and Southern Anatolian regions in 3 Turkey (84%, 82% respectively). A study performed by Yalcın SS et al. between 1988-2010, mentioned that the mortality rates of children younger than 5 years of age decreased more than 2/3’s due to the applied vaccination program 68 TURKISH JOURNAL OF FAMILY MEDICINE AND PRIMARY CARE (TJFMPC) ▪ www.tjfmpc.com ▪ VOL.8, NO.3 ▪ SEPTEMBER 2014 Original Research Kut and Geçkil Hib I II III R OPV I II III R MMR Hepatitis B R I I II Eight grade of Primary School R First grade of Primary School III 24th month II 18th month I 12th month DTP End of 6th month I End of 1st month BCG At birth End of 4th month program consisted of only basic vaccines such as BCG, DTP, OPV, Measles; extended advisory meetings updated the program to a status which is nowadays more advanced than it is in many other 2 European countries. The aim of this investigation was to determine not only the demographic traits but also the vaccination status of children less than 8 years of age; also attitudes, and behaviors of their parents regarding national vaccination approaches. End of 3rd month End of 2nd month supplied and directed by the funds of the Ministry 5 of Health. Fortunately the rates of vaccinated children in Turkey increased from year to year and reached a level of 97% according to the Ministry of 6 Health’s data by the year 2012. The National Vaccination Program (figure1), which is applied under the supervision of the Ministry of Health inTurkey is not only one of the key elements of primary care services, but also an inevitable part in the assessmentof national health status. While until 2005 the national vaccination R III I-II-III* Td V V Rubella V* Hepatitis A I Varicella II I *Until the incomplete vaccinated cohort completed 4 Figure1.Turkish National Vaccination Program-2013 Table 1.Demographic traits of the study population Parameters Gender Age Living Environment Number of Children n % Male 52 34.7 Female 98 65.3 18-25 18 12.0 26-30 46 30.7 31-35 47 31.3 36-40 23 15.3 > 40 16 10.7 Urban 115 76.7 Rural 35 23.4 1 92 61.4 2 47 31.3 69 TURKISH JOURNAL OF FAMILY MEDICINE AND PRIMARY CARE (TJFMPC) ▪ www.tjfmpc.com ▪ VOL.8, NO.3 ▪ SEPTEMBER 2014 Original Research Kut and Geçkil ≥3 Materials and Method This cross sectional study was carried out at the pediatrics outpatient clinic of Baskent University Ankara Hospital on 0-8 years of age children, and their parents using a 12-item questionnaire. All subjects were interviewed by the same investigator in a face to face manner. Between March – June 2013,219 children of total150 families were enrolled the study. During the study period all patients who applied to the pediatrics outpatient clinic were invited to join the study, and only families who volunteered to join the study group were enrolled. Volunteering familieswere informed about study objectives and signed an informed consent to attend the research. Families living in “city centers” were mentioned as “urban”, and those in “county centers” were mentioned as “rural” throughout the manuscript. All collected data were analyzed using the SPSS software (SPSS 21.0 for Windows; Chicago-IL, USA). For continuous variables descriptive statistics were performed using mean± standard deviation, minimummaximum level; for categorical variables frequencies, and percentages were evaluated. Relations between continuous variables were determined using Pearson correlation analysis, and t- test. The evaluation of categorical variables was performed using Chi-square tests. P values < 0.05 with a confidence interval of 95% were accepted as statistically significant. Results A total number of 150 families were enrolled. 34.7% (n=52) of the participating parents were male, and 65.3% (n=98) were female with a male to female ratio of 0.53:1. Of them 61.4 % (n=92) had only one child. The study investigated totally 219 children of 150 families. Of them, 49.7% (n=109) were boys, and 50.3% (n=110) were girls. The mean age of the children was 3.49±3.23 years. Most of the participants were living in the city center (76.7%). The distribution of mean number of children per family according to urban, and rural areas were 1.41±0.62 and 1.63±0.64 respectively (p=0.71). When analyzing the ages of the parents, 62% of them were accumulated between 26-35 years of age. Major demographic data are shown in Table-1. All children (100%) of enrolled families were completely vaccinated according to the TurkishNational Vaccination Program appropriate to their ages. Opinions of the families regarding 11 7.3 paid vaccines which are currently not covered in the national vaccination program and had to be performed according to the request of the families or their doctors are shown in Table-2. Although vaccines in the national program were fully trusted and performed, 10.7 % of the families (n=16) were against paid vaccines owing to concerns regarding possible side effects. Only 2% of the families stated that they are financially not able to afford paid vaccines.There was no statistical significance between families living in urban, and rural regions regarding attitudes towards paid vaccines (p=0.139). The performed rates of vaccines newly added to the national vaccination program like varicella, and hepatitis A were 74.6%, and 59.4% respectively (added in 2013). Regarding HPV vaccination 42% of families were positive about the HPV vaccine, while 18% had concerns or were against HPV vaccination. There was also no statistically significant difference between families living in urban, and rural regions regarding attitudes towards HPV vaccination (p=0.325). Attitudes towards paid vaccines related to the gender of their children were almost equally distributed and showed no statistical difference between boys, and girls (70.3%; 68.1% respectively). Most of the families vaccinate their children by their family physicians (63.1%), claiming that access to appropriate vaccines are easier in primary care units (40.7%).Those are followed by university hospital child care centers (15.4%), and private medical practices and private hospitals (17.4%), while state hospitals were less preferred (4%) by families (Table-3). When analyzing differences between children vaccinated in different types of health care facilities among urban and rural areas; the data revealed that while family medicine centers were almost equally most preferred in both areas, the second and the third most preferred facilities differed significantly. University hospitals were the second most chosen facilities in urban areas for vaccination; on the other hand, state hospitals were significantly more used in rural areas (Table4). Discussion Contagious diseases are one of the major health care concerns especially in developing countries. Almost all countries carried out national vaccination programs to challenge, and eradicate 1 these health issues with different rate of success. 70 TURKISH JOURNAL OF FAMILY MEDICINE AND PRIMARY CARE (TJFMPC) ▪ www.tjfmpc.com ▪ VOL.8, NO.3 ▪ SEPTEMBER 2014 Original Research Kut and Geçkil Turkey moved a long way from the past till today contagious pathogens. While according to the to cover all of the population affecting pediatric Turkish Statistical Institute’s data (TÜİK) the ratio Table 2.Attitudes towards paid vaccines and HPV vaccination Attitudes About Paid Vaccines Urban Rural Total I am willing to afford paid vaccines 84 22(62.9 106 (73%) %) (70.7%) I cannot afford it 2 1 3 (1.7%) (2.9%) (2.0%) I am not willing due to possible side 14 2 16 effects (12.2%) (5.7%) (10.7%) I have no idea 15 10 25 (13.0%) (28.6%) (16.7%) 115 35 150 Total (100%) (100%) (100%) Chi-square test: p= 0.139 About HPV Vaccination I am positive about the HPV vaccine 46 17 63 to make (40.0%) (48.6%) (42.0%) I am negative about the HPV vaccine 7 0 7 to make (6.1%) (0.0%) (4.7%) I am positive but have concerns 17 3 20 (side effects, efficiency, etc..) (14.8%) (8.6%) (13.3%) 45 15 60 I have no idea (39.1%) (42.9%) (40%) 115 35 150 Total (100%) (100%) (100%) Chi-square test: p= 0.325 Table 3.Current and preferred facilities for vaccination Current facility for vaccination Frequency Percentage Family Healthcare 95 63.3 Center Private 9 6.0 Practice Private 17 11.3 Hospital State 6 4.0 Hospital University 23 15.3 Hospital Total 150 100 Preferred facility for vaccination Frequency Percentage 81 54.0 6 4.0 12 8.0 8 5.3 43 28.7 150 100 71 TURKISH JOURNAL OF FAMILY MEDICINE AND PRIMARY CARE (TJFMPC) ▪ www.tjfmpc.com ▪ VOL.8, NO.3 ▪ SEPTEMBER 2014 Original Research Kut and Geçkil Table 4.Urban and rural differences in current usage of health care facilities for vaccination Urban Rural Frequency Percentage Frequency Family Healthcare 71 61.7 24 Center Private 7 6.1 2 Practice Private 14 12.2 3 Hospital State 2 1.7 4 Hospital University 21 18.3 2 Hospital Total 115 100 35 Chi-square test: p=0.048 of children in the Turkish population in the 70s was 48.5%, by the year 2012 this number has declined to 30%. Further projections are reflecting that this ratio will continue to decline and reach to 19.1% by 7 the year 2050. Although these projections shows that the total number of children in Turkey will continue to decrease over the next decades, both primary care services, and the national vaccination committee of the ministry of health keep on working to accomplish a higher status of protection against contagious diseases, which we hope will further increase the vaccination rates in Turkey. The overall vaccination status in 1994 was 81% which was way below the rates of developed 6 countries, and WHO Europe regions. Despite to fundamental changes in the national vaccination program, and policies regarding vaccination campaigns; this figure continued to fall and 6 became 78% by the year 2002. With the initiation of family medicine in 2004, andalso due to the recent changes in the national vaccination program the proportion of vaccinated children started to increase quickly and rose up to 97% by the year 6 2012. Whereas the mean rates of vaccinated children worldwide in 2010is 85%, and the rate of 6 WHO Europe region is %96 by the year 2010. Some recent studies performed in Turkey claim that the fully vaccination rate of children are decreasing after initiation of the family medicine system in 2010 in Turkey. A study held by Cakir et al in 2008, performed using the lot quality system in Ankara-Kecioren shows that the total vaccination coverage was 28 over 33 lots with an 8 acceptance rate of 75%. On the other hand a recent study by Ozcirpici et al conducted in Gaziantep and published in 2014 claims that after Percentage 68.6 5.7 8.6 11.4 5.7 100 the family medicine initiation in 2010, the total vaccination coverage has significantly decreased and became 29 over 50 lots with an acceptance 9 rate of 85%. In addition to these studies another investigation published in 2012 which was held in various cities by Uner et al. stated that the vaccination coverage is 59 over 63 lots with an 10 acceptance rate of 75%. The significant decrease in vaccination coverage claimed by the study of Ozcirpici et al might be due to the higher acceptance rate of 85%, while previously mentioned similar studies were using an acceptance rate of 75%. All these studies demonstrate that although the family medicine application is new to Turkey (2010), the over allvaccination rate is satisfactory. It is also remarkable that all of these studies are indicating that most of the vaccinations were performed in primary care units. Our study is also concordant with these studies in this regard. Since the accessibility of university clinics, , and private clinics in metropolises like Ankara is higher compared to cities in which the mentioned articles were carried out, the rate of vaccinations performed in primary health care units is still over 60% in urban, and 65% in rural areas. This fact indicates that access to primary care units, and vaccination follow-ups are well organized and performed as it should be. Due to the current healthcare policies, and the introduction of family medicine centers both in rural, and urban areas; it has become much easier to access primary health care services. As a result, it is found that rates of appliances to family healthcare centers are almost equal and high in their rates both in urban, and rural regions, which 72 TURKISH JOURNAL OF FAMILY MEDICINE AND PRIMARY CARE (TJFMPC) ▪ www.tjfmpc.com ▪ VOL.8, NO.3 ▪ SEPTEMBER 2014 Original Research let us predict that the population is highly adapted to the new system of family medicine. While according to our findings the alternative facilities to family medicine centers in rural regions are state hospitals, university hospitals are replacing them in urban regions. The major factor by doing so is the accessibility of these facilities, as the case is withuniversity centers whichare regularly located in urban areas. The present study comprises of subjects living in a geographical region known to have a relatively higher socio-economical status. Consequently, we expected and found a higher vaccination rate (100%) compared to national figures, which indicated that parents are extremely aware to comply with the national vaccination program. Even vaccines, which are currently not included in the national program and should be paid are highly requested and performed. Only the acceptance and awareness towards HPV vaccination was below our expectations, which revealed that about 40% of the participants still have poor information about it. Another possible factor of the low acceptance rate for the HPV vaccination may be the high costs of this vaccination. The weakness of this study is that it includes only children attending to a certain outpatient clinic instead of a certain geographic region and comprises a wide range of ages instead of a sample of 12-24 month children. Another issue is that a correct analysis has to be done with a more structured outline like a “lot of quality” survey. Since researchers from various branches may have insufficient information regarding the practice, and application of current clinical preventive approaches; we advise family physicians as researchers, to perform this kind of structured surveys in their working areas to collect appropriate information to outline their work regarding vaccination issues. In conclusion, although the application of family medicine is new in Ankara-Turkey (2010) the trust in primary care units regarding vaccination is satisfactory and gives hope for the future. The high rates of vaccination both in urban, and rural areas are showing the extraordinary success of both the Turkish national vaccination program, and the efforts of primary care physicians. However, there are still many factors threatening these efforts in our country, the major one being the recent geopolitical decisions, and changes especially across the southern border of Turkey. The ongoing dispute inthe neighboring countries may cause some of the eradicated contagious diseases like polio, and measles to arise. Health care officials in Kut and Geçkil Turkey are not only trying to determine the current vaccination status in the region but also evaluating needed precautions that have to be carried out in order to protect the public health of the society. This and similar factors will be the major challenges of the Turkish primary health care system in the near future, and family physicians have to be skilled enough and preparedto get through these overwhelming issues. References 1.World Health Organization : Guide for standardization of economic evaluations of immunization programmes. World Health Organization Publications. Accessed October 10, 2013, at http://whqlibdoc.who.int/hq/2008/WHO_IVB_08.1 4_eng.pdf . 2.Ceyhan M. Recentimprovements in the Turkish childhood national immunization program. Turk J Pediatr 2010;52(6):563-569. 3.Child Health. Turkey Demographic and Health Survey 2008. Hacettepe Publications. Accessed February26, 2014, at http://www.hips.hacettepe.edu.tr/eng/dokumanla r/TDHS-2008_Main_Report.pdf 4.Childhood Vaccination Schedule - Turkey. Turkish Ministry of Health. Accessed March 09, 2014, at http://www.saglik.gov.tr/EN/belge/244/childhood-vaccination-schedule---turkey.html. 5.Yalcin SS, Tezel B, Kose MR, Tugay D, Mollahaliloglu S, Erkoc Y. Change sand determinants in under-five mortality rate in Turkey since 1988. Cent Eur J Public Health 2013;21(2):8087. 6.2012 Annual Report. Turkish Ministry of Health. Accessed March 05, 2014, at http://saglik.gov.tr/TR/dosya/182968/h/faaliyetraporu2012.pdf. 7.Istatistiklerle Cocuk 2012. TUIK Haber Bulteni 22 Nisan 2013; 13488. Accessed March 05, 2014, at http://www.tuik.gov.tr/PreHaberBultenleri.do?id= 13488. 8.Cakir B, Uner S, Temel F, Akin L. Lot quality survey: an appealing method for rapid evaluation of vaccine coverage in developing countries– experience in Turkey. BMC Public Health 2008; 8:240. 9.Ozcirpici B, Aydin N, Coskun F, Tuzun H, Ozgur S. Vaccination coverage of children aged 12-23 months in Gaziantep, Turkey: comparative results of two studies carried out by lot quality technique: what changed after family medicine?. BMC Public Health 2014; 14:217. 73 TURKISH JOURNAL OF FAMILY MEDICINE AND PRIMARY CARE (TJFMPC) ▪ www.tjfmpc.com ▪ VOL.8, NO.3 ▪ SEPTEMBER 2014 Original Research 10.Uner S, Ozelci P, Com S, Kosdak M, Mollahaliloglu S, Erkoc Y. Vaccine coverage rates among 12-23 month old children living in four selected provinces of Turkey: results of a lot quality Kut and Geçkil survey. Turkiye Klinikleri J Med Sci 2012;32(4):952962. 74 TURKISH JOURNAL OF FAMILY MEDICINE AND PRIMARY CARE (TJFMPC) ▪ www.tjfmpc.com ▪ VOL.8, NO.3 ▪ SEPTEMBER 2014